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Oregon Bulletin

September 1, 2011

 

Oregon Health Authority,
Division of Medical Assistance Programs
Chapter 410

Rule Caption: Re-file due to federal input to implement, administer and audit the Oregon Medicaid EHR Incentive Program.

Adm. Order No.: DMAP 20-2011

Filed with Sec. of State: 7-21-2011

Certified to be Effective: 7-22-11

Notice Publication Date: 7-1-2011

Rules Adopted: 410-165-0060

Subject: The Medicaid Electronic Health Records (EHR) Incentive Program administrative rules govern Division payments for services to certain eligible providers.

      The Division adopted the Medicaid Electronic Health Records (HER) Incentive Program effective July 1, 2011, having received approval from the Centers for Medicare and Medicaid Services (CMS). However OAR 410-165-0060 was delayed due to clarification from CMS in section (2) (b) (C) and Table 165-0060-1 related to the eligibility criteria for patient volume requirements of eligible professionals practicing in Federally Qualified Health Centers and Rural Health Clinics. The Division determined this to be a substantive change requiring the need to re-file the rule with the Secretary of State and allow a new Public Comment Period to end July 18
giving the public opportunity to comment on the rule change. The Division adopted the rule effective July 22, 2011.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-165-0060

Eligibility

For the purposes of the Medicaid Electronic Health Record (EHR) Incentive Program Oregon Administrative Rules, chapter 410, division 165, there are three categories of eligibility criteria, which include criteria for a professional, a professional practicing predominately in a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC), and a hospital:

(1) A professional, as listed in Table 165-0060-1, must meet the Medicaid EHR Incentive Program criteria each year to be eligible for a Medicaid EHR incentive payment for the payment year:

(a) The professional types who are eligible for the Medicaid EHR Incentive Program are:

(A) A physician;

(B) A dentist; and

(C) A nurse practitioner, including a nurse-midwife nurse practitioner;

(b) To be eligible for an incentive payment, an eligible professional must, at a minimum:

(A) Meet and follow the scope of practice regulations, as applicable for each professional as defined in 42 CFR Part 440;

(B) Meet the following certified EHR technology and meaningful use requirements for the corresponding payment year:

(i) First payment year: Adopt, implement, or upgrade certified EHR technology; and

(ii) Subsequent payment years: Demonstrate meaningful use as prescribed by 42 CFR 495.8 and meet the corresponding meaningful use criteria for the payment year as prescribed by 42 CFR 495.6;

(C) Not be hospital-based; and

(D) Meet one of the following criteria:

(i) Have a minimum of 30 percent patient volume attributable to individuals receiving Medicaid; or

(ii) Have a minimum of 20 percent patient volume attributable to individuals receiving Medicaid, and be a pediatrician;

(c) An eligible professional must calculate patient volume, as listed in Table 165-0060-2, by using:

(A) The patient volume calculation method of:

(i) Patient encounter; or

(ii) Patient panel that may only be used when all of the following apply:

(I) The patient panel is appropriate as a patient volume calculation method for the eligible professional; and

(II) There is an auditable data source to support the patient panel data;

(B) The patient volume of the:

(i) Eligible professional; or

(ii) Group that may only be used when all of the following apply:

(I) The group’s patient volume is appropriate to use in the patient volume calculation for the eligible professional;

(II) There is an auditable data source to support the group’s patient volume data;

(III) All eligible professionals in the group must use the same patient volume calculation method for the payment year;

(IV) The group uses the entire practice or clinic’s patient volume, including non-eligible providers who are billing, rendering and ancillary providers, and does not limit patient volume in any way; and

(V) If an eligible professional works inside and outside of the group, then the patient volume calculation includes only those encounters associated with the group, and not the eligible professional’s outside encounters;

(C) To calculate Medicaid patient volume using the patient encounter calculation method based on:

(i) The eligible professional’s patient volume, the eligible professional must divide the total Medicaid encounters of the eligible professional in any representative, continuous 90-day period in the preceding calendar year by the total patient encounters of the eligible professional in the same 90-day period; or

(ii) The group’s patient volume, the eligible professional must divide the total Medicaid encounters of the group in any representative, continuous 90-day period in the preceding calendar year by the total patient encounters of the group in the same 90-day period;

(D) To calculate Medicaid patient volume using the patient panel calculation method based on:

(i) The eligible professional’s patient volume, the eligible professional must divide the total Medicaid patients assigned to the eligible professional’s panel in any representative, continuous 90-day period in the preceding calendar year when at least one Medicaid encounter took place with the Medicaid patient in the preceding calendar year plus the eligible professional’s unduplicated Medicaid encounters in the same 90-day period by the total patients assigned to the eligible professional’s panel in that same 90-day period with at least one encounter taking place with the patient during the preceding calendar year plus all of the unduplicated patient encounters of the eligible professional in the same 90-day period; or

(ii) The group’s patient volume, the eligible professional must divide the total Medicaid patients assigned to the group’s panel in any representative, continuous 90-day period in the preceding calendar year when at least one Medicaid encounter took place with the Medicaid patient in the preceding calendar year plus the group’s unduplicated Medicaid encounters in the same 90-day period by the total patients assigned to the group’s panel in that same 90-day period with at least one encounter taking place with the patient in the preceding calendar year plus all of the unduplicated patient encounters of the group in the same 90-day period.

(2) To be eligible for a Medicaid EHR incentive payment for the payment year, a professional practicing predominately in an FQHC or an RHC, as listed in Table 165-0060-1, must meet the Medicaid EHR Incentive Program professional eligibility criteria each year, by meeting either the above section (1) of this rule or by meeting the following FQHC- and RHC-specific criteria:

(a) The professional types who are eligible for the Medicaid EHR Incentive Program are:

(A) A physician;

(B) A dentist;

(C) A nurse practitioner, including a nurse-midwife nurse practitioner; and

(D) A physician assistant practicing in an FQHC or RHC that is so led by a physician assistant;

(b) To be eligible for an incentive payment, an eligible professional must, at a minimum:

(A) Meet and follow the scope of practice regulations, as applicable for each professional as prescribed by 42 CFR Part 440;

(B) Meet the following certified EHR technology and meaningful use requirements for the corresponding payment year:

(i) First payment year: Adopt, implement, or upgrade certified EHR technology; and

(ii) Subsequent payment years: Demonstrate meaningful use as prescribed by 42 CFR 495.8 and meet the corresponding meaningful use requirements for the payment year as prescribed by 42 CFR 495.6; and

(C) Have a minimum of 30 percent patient volume attributable to needy individuals;

(c) An eligible professional must calculate patient volume, as listed in Table 165-0060-3, by using:

(A) The patient volume calculation method of:

(i) Patient encounter; or

(ii) Patient panel that may only be used when all of the following apply:

(I) The patient panel is appropriate as a patient volume calculation method for the eligible professional; and

(II) There is an auditable data source to support the patient panel data;

(B) The patient volume of the:

(i) Eligible professional; or

(ii) Group that may only be used when all of the following apply:

(I) There is an auditable data source to support the group’s patient volume data;

(II) All eligible professionals in the group must use the same patient volume calculation method for the payment year;

(III) The group uses the entire practice or clinic’s patient volume, including non-eligible providers who are billing, rendering and ancillary providers, and does not limit patient volume in any way; and

(IV) If an eligible professional works inside and outside of the group, then the patient volume calculation includes only those encounters associated with the group, and not the eligible professional’s outside encounters;

(C) To calculate needy individual patient volume using the patient encounter calculation method based on:

(i) The eligible professional’s patient volume, the eligible professional must divide the total needy individual encounters of the eligible professional in any representative, continuous 90-day period in the preceding calendar year by the total patient encounters of the eligible professional in the same 90-day period; or

(ii) The group’s patient volume, the eligible professional must divide the total needy individual encounters of the group in any representative, continuous 90-day period in the preceding calendar year by the total patient encounters of the group in the same 90-day period;

(D) To calculate needy individual patient volume using the patient panel calculation method based on:

(i) The eligible professional’s patient volume, the eligible professional must divide the total needy individual patients assigned to the eligible professional’s panel in any representative, continuous 90-day period in the preceding calendar year with at least one encounter taking place with the needy individual patient in the preceding calendar year plus unduplicated needy individual encounters in the same 90-day period by the total patients assigned to the eligible professional’s panel in that same 90-day period with at least one encounter taking place with the patient in the preceding calendar year plus all unduplicated patient encounters of the eligible professional in the same 90-day period; or

(ii) The group’s patient volume, the eligible professional must divide the total needy individual patients assigned to the group’s panel in any representative, continuous 90-day period in the preceding calendar year when at least one encounter took place with the needy individual patient in the preceding calendar year plus unduplicated needy individual encounters of the group in the same 90-day period by the total patients assigned to the group’s panel in that same 90-day period with at least one encounter taking place with the patient during the preceding calendar year plus all unduplicated patient encounters of the group in the same 90-day period.

(3) An eligible hospital must meet the Medicaid EHR Incentive Program criteria each year to be eligible for a Medicaid EHR incentive payment for the payment year:

(a) The hospital types that are eligible for the Medicaid EHR Incentive Program are:

(A) A children’s hospital; and

(B) An acute care hospital;

(b) To be eligible for an incentive payment, an eligible hospital must, at a minimum:

(A) Meet the certified EHR technology and meaningful use requirements for the corresponding payment year:

(i) First payment year: Adopt, implement, or upgrade certified EHR technology; and

(ii) Subsequent payment years: Demonstrate meaningful use as prescribed by 42 CFR 495.8 and meet the corresponding meaningful use criteria for the payment year as prescribed by 42 CFR 495.6; and

(B) Meet one of the following:

(i) Be an acute care hospital with at least a 10 percent Medicaid patient volume; or

(ii) Be a children’s hospital that is exempt from meeting a patient volume threshold;

(c) An eligible acute care hospital must calculate patient volume by dividing the total eligible hospital Medicaid encounters in any representative, continuous 90-day period in the preceding federal fiscal year by the total encounters in the same 90-day period.

(4) Table 165-0060-1

(5) Table 165-0060-2

(6) Table 165-0060-3

[ED. NOTE: Tables referenced are available from the agency.]

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 409.010, 413.042 & 414.033

Hist.: DMAP 20-2011, f. 7-21-11, cert. ef. 7-22-11

 

Rule Caption: Align with OAR chapter 461, division 155 medical eligibility rules.

Adm. Order No.: DMAP 21-2011(Temp)

Filed with Sec. of State: 7-29-2011

Certified to be Effective: 8-1-11 thru 1-11-12

Notice Publication Date:

Rules Amended: 410-120-0006

Rules Suspended: 410-120-0006(T)

Subject: The General Rules Program administrative rules govern the Division’s payments for services provided to clients, and medical assistance eligibility determinations made by the Oregon Health Authority. In coordination with the Department of Human Services’ (Department), temporary revision of medical eligibility rules in chapter 461, the Division temporarily amended OAR 410-120-0006 to assure that the Division’s medical eligibility rule aligns with and reflects information found in the Department’s medical eligibility rules. In OAR 410-120-0006, the Division adopts in rule by reference Department eligibility rules and must update OAR 410-120-0006 to reflect the most current effective date. The Division intends to file this rule permanently on or before January 11, 2012.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-120-0006

Medical Eligibility Standards

As the state Medicaid and CHIP agency, the Oregon Health Authority (Authority) is responsible for establishing and implementing eligibility policies and procedure consistent with applicable law. As outlined in 943-001-0020, the Authority, and the Department of Human Services (Department) work together to adopt rules to assure that medical assistance eligibility procedures and determinations are consistent across both agencies.

(1) The Authority adopts and incorporates by reference the rules established in OAR Chapter 461, and in effect August 1, 2011, for all medical eligibility requirements for medical assistance when the Authority conducts eligibility determinations.

(2) Any reference to OAR Chapter 461 in Oregon Administrative Rules or contracts of the Authority are deemed to be references to the requirements of this rule, and shall be construed to apply to all eligibility policies, procedures and determinations by or through the Authority.

(3) For purposes of this rule, references in OAR chapter 461 to the Department or to the Authority shall be construed to be references to both agencies.

(4) Effective on or after July 1, 2011 the Authority shall conduct medical eligibility determinations using the OAR chapter 461 rules which are in effect on the date the Authority makes the medical eligibility determination.

(5) A request for a hearing resulting from a determination under this rule, made by the Authority shall be handled pursuant to the hearing procedures set out in division 25 of OAR Chapter 461. References to “the Administrator” in division 25 of chapter 461 or “the Department” are hereby incorporated as references to the” Authority.”

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.065

Hist.: DMAP 10-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 18-2011(Temp), f. & cert. ef. 7-15-11 thru 1-11-12; DMAP 21-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-11-12

 

Rule Caption: Legislatively-approved budget with provider rate changes.

Adm. Order No.: DMAP 22-2011(Temp)

Filed with Sec. of State: 7-29-2011

Certified to be Effective: 8-1-11 thru 1-25-12

Notice Publication Date:

Rules Amended: 410-120-1340, 410-121-0160, 410-122-0186, 410-122-0630, 410-127-0060, 410-130-0595

Subject: The Division of Medical Assistance Program administrative rules govern payments for services provided to eligible clients. The General Rules, Pharmaceutical Services, DMEPOS, Home Health Services and Medical-Surgical Services temporarily amended rules listed above to implement rate changes to specified fee-for-service providers to comply with budget limitations required by the 2011 Legislative Assembly in SB 5529. Implementation of these amendments is subject to approval by the Centers for Medicare and Medicaid Services (CMS).

      The Division amended the following:

      • 410-120-1340 – Relative Value Units (RVU) and anesthesia conversion factor

      • 410-121-0160 – Pharmacy dispensing fee claim volume schedule

      • 410-122-0186 – DMEPOS fee schedule and utilization limits

      • 410-122-0630 – Incontinence

      • 410-127-0060 – Home Health rates (including medical supply daily maximum)

      • 410-130-0595- Maternity Case Management – Eliminate reimbursement for both Case Management and High Risk Case Management; and, change Telephone CM Visit to outside home.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-120-1340

Payment

(1) The Division of Medical Assistance Programs (Division) shall make payment only to the enrolled provider who actually performs the service or to the provider’s enrolled billing provider for covered services rendered to eligible clients. Any contracted billing agent or billing service submitting claims on behalf of a provider but not receiving payment in the name of or on behalf of the provider does not meet the requirements for billing provider enrollment. If billing agents and billing services intend to submit electronic transactions they must register and comply with the Oregon Health Authority (Authority) Electronic Data Interchange (EDI) rules, OAR 407-120-0100 through 407-120-0200. Division reimbursement for services may be subject to review prior to reimbursement.

(2) The Division (Division of Medical Assistance Programs or another Division within the Authority) that is administering the program under which the billed services or items are provided sets fee-for-service (FFS) payment rates.

(3) The Division uses FFS payment rates in effect on the date of service that are the lesser of:

(a) The amount billed;

(b) The Division maximum allowable amount or;

(c) Reimbursement specified in the individual program provider rules:

(A) Amount billed may not exceed the provider’s “usual charge” (see definitions);

(B) The Division’s maximum allowable rate setting process uses the following methodology. The rates are updated periodically and posted on the Authority web site at http://www.oregon.gov/Department/healthplan/data_pubs/feeschedule/main.shtml:

(C) For all CPT/HCPCS codes assigned a Relative Value Unit (RVU) weight and reflecting services not typically performed in a facility, the Division shall continue to use the 2010 Transitional Non-Facility Total RVU weights published in the Federal Register, Vol. 74, November 25, 2009 with technical corrections published Dec. 10, 2009, to be effective for dates of services beginning January 1, 2011. For CPT/HCPCS codes for professional services typically performed in a facility the Transitional Facility Total RVU weight shall be adopted:

(i) The conversion factor for labor and delivery (59400-59622) is $41.61;

(ii) CPT codes 92340-92342 and 92352-92353 remain at a flat rate of $26.81;

(iii) The conversion factor for Primary care providers and services is 27.82. A current list of Primary care CPT, HCPCs and provider specialty codes is available at http://www.oregon.gov/OHA/healthplan/data_pubs/
feeschedule/main.shtml The document dated:

(I) August 1, 2011, is effective for dates of service on or after August 1, 2011.

(iv) All remaining RVU weight based CPT/HCPCS codes have a conversion factor of $26.00;

(B) Surgical assist reimburses at 20% of the surgical rate;

(C) The base rate for anesthesia services 00100-01996 is $ 21.20 and is based on per unit of service;

(D) Clinical lab codes are priced at 70% of the Medicare clinical lab fee schedule;

(E) All approved Ambulatory Surgical Center (ASC) procedures are reimbursed at 80% of the Medicare fee schedule;

(F) Physician administered drugs, billed under a HCPCS code, are based on Medicare’s Average Sale Price (ASP). When no ASP rate is listed the rate shall be based upon the Wholesale Acquisition Price (WAC) plus 6.25%. If no WAC is available, then the rate shall be reimbursed at Acquisition Cost. Pricing information for WAC is provided by First Data Bank. These rates may change periodically based on drug costs;

(G) All procedures used for vision materials and supplies are based on contracted rates that include acquisition cost plus shipping and handling;

(c) Individual provider rules may specify reimbursement rates for particular services or items.

(4) The Division reimburses inpatient hospital service under the DRG methodology, unless specified otherwise in the Division’s Hospital Services Program administrative rules (chapter 410, division 125). Reimbursement for services, including claims paid at DRG rates, shall not exceed any upper limits established by federal regulation.

(5) The Division reimburses all out-of-state hospital services at Oregon DRG or FFS rates as published in the Hospital Services Program rules (OAR chapter 410, division 125) unless the hospital has a contract or service agreement with the Division to provide highly specialized services.

(6) Payment rates for in-home services provided through Department of Human Services (Department) Seniors and People with Disabilities Division (SPD) will not be greater than the current Division rate for nursing facility payment.

(7) The Division sets payment rates for out-of-state institutions and similar facilities, such as skilled nursing care facilities, psychiatric and rehabilitative care facilities at a rate that is:

(a) Consistent with similar services provided in the State of Oregon; and

(b) The lesser of the rate paid to the most similar facility licensed in the State of Oregon or the rate paid by the Medical Assistance Programs in that state for that service; or

(c) The rate established by SPD for out-of-state nursing facilities.

(8) The Division shall not make payment on claims that have been assigned, sold, or otherwise transferred or when the billing provider, billing agent or billing service receives a percentage of the amount billed or collected or payment authorized. This includes, but is not limited to, transfer to a collection agency or individual who advances money to a provider for accounts receivable.

(9) The Division shall not make a separate payment or copayment to a nursing facility or other provider for services included in the nursing facility’s all-inclusive rate. The following services are not included in the all-inclusive rate (OAR 411-070-0085) and may be separately reimbursed:

(a) Legend drugs, biologicals and hyperalimentation drugs and supplies, and enteral nutritional formula as addressed in the Pharmaceutical Services Program administrative rules (chapter 410, division 121) and Home Enteral/Parenteral Nutrition and IV Services Program administrative rules, (chapter 410, division 148);

(b) Physical therapy, speech therapy, and occupational therapy provided by a non-employee of the nursing facility within the appropriate program administrative rules, (chapter 410, division 129 and 131);

(c) Continuous oxygen which exceeds 1,000 liters per day by lease of a concentrator or concentrators as addressed in the Durable Medical Equipment, Prosthetics, Orthotics and Supplies Program administrative rules, (chapter 410, division 122);

(d) Influenza immunization serum as described in the Pharmaceutical Services Program administrative rules, (chapter 410, division 121);

(e) Podiatry services provided under the rules in the Medical-Surgical Services Program administrative rules, (chapter 410, division 130);

(f) Medical services provided by a physician or other provider of medical services, such as radiology and laboratory, as outlined in the Medical-Surgical Services Program rules, (chapter 410, division 130);

(g) Certain custom fitted or specialized equipment as specified in the Durable Medical Equipment, Prosthetics, Orthotics and Supplies Program administrative rules, (chapter 410, division 122).

(10) The Division reimburses hospice services based on CMS Core-Based Statistical Areas (CBSA’s). A separate payment will not be made for services included in the core package of services as outlined in OAR chapter 410, division 142.

(11) Payment for Division clients with Medicare and full Medicaid:

(a) The Division limits payment to the Medicaid allowed amount less the Medicare payment up to the Medicare co-insurance and deductible, whichever is less. The Division’s payment cannot exceed the co-insurance and deductible amounts due;

(b) The Division pays the Division allowable rate for Division covered services that are not covered by Medicare.

(12) For clients with third-party resources (TPR), the Division pays the Division allowed rate less the TPR payment but not to exceed the billed amount.

(13) The Division payments, including contracted Prepaid Health Plan (PHP) payments, unless in error, constitute payment in full, except in limited instances involving allowable spend-down or copayments. For the Division, such payment in full includes:

(a) Zero payments for claims where a third party or other resource has paid an amount equivalent to or exceeding Division allowable payment; and

(b) Denials of payment for failure to submit a claim in a timely manner, failure to obtain payment authorization in a timely and appropriate manner, or failure to follow other required procedures identified in the individual provider rules.

(14) Payment by the Division does not restrict or limit the Authority or any state or federal oversight entity’s right to review or audit a claim before or after the payment. Claim payment may be denied or subject to recovery if medical review, audit or other post-payment review determines the service was not provided in accordance with applicable rules or does not meet the criteria for quality of care, or medical appropriateness of the care or payment.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025, 414.033, 414.065, 414.095, 414.705, 414.727, 414.728, 414.742, 414.743

Hist.: PWC 683, f. 7-19-74, ef. 8-11-784; PWC 803(Temp), f. & ef. 7-1-76; PWC 812, f. & ef. 10-1-76; Renumbered from 461-013-0061; PWC 833, f. 3-18-77, ef. 4-1-77; Renumbered from 461-013-0061; AFS 5-1981, f. 1-23-81, ef. 3-1-81; Renumbered from 461-013-0060, AFS 47-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 117-1982, f. 12-30-82, ef. 1-1-83; AFS 24-1985, f. 4-24-85, ef. 6-1-85; AFS 50-1985, f. 8-16-85, ef. 9-1-85; HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0081, 461-013-0085, 461-013-0175 & 461-013-0180; HR 41-1991, f. & cert. ef. 10-1-91; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0040, 410-120-0220, 410-120-0200, 410-120-0240 & 410-120-0320; HR 2-1994, f. & cert. ef. 2-1-94; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 10-1999, f. & cert. ef. 4-1-99; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03; OMAP 10-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06; OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 24-2007, f. 12-11-07 cert. ef. 1-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 35-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12

410-121-0160

Dispensing Fees

(1) Effective August 1, 2011 professional dispensing fees allowable for services shall be reimbursed as follows:

(a) All enrolled chain affiliated pharmacies shall be reimbursed at a rate of $9.68 per claim;

(b) Independently owned pharmacies in communities that are the only enrolled pharmacy within a fifteen (15) mile radius from another pharmacy shall be reimbursed at a dispensing fee of $14.01 per claim;

(c) All other enrolled independently owned pharmacies excluding those in 410-121-0160(b) shall be reimbursed based on an individual pharmacy’s annual claims volume as follows:

(A) Less than 29,999 claims a year = $14.01;

(B) Between 30,000 and 49,999 claims per year = $10.14;

(C) 50,000 or more claims per year = $9.68.

(2) All Division enrolled independent pharmacies shall be required to complete an annual survey that collects claim volumes from enrolled pharmacies and other information from the previous 12 month period to determine the appropriate dispensing fee reimbursement:

(a) Claims volume shall be stated by total OHP covered prescriptions and claims from all payer types;

(b) Survey activities shall be conducted by either the Division or its contractor and must be completed and returned by pharmacies within 14 days of receipt;

(c) Completed surveys must be signed with a letter of attestation by the store owner or majority owner;;

(d) Pharmacies that fail to respond to the survey or do not include the letter of attestation shall default to the lowest dispensing tier;

(e) Once a tier is established for a calendar year, the pharmacy’s dispensing fee shall remain in that tier until the next annual claims volume survey is conducted;

(f) Newly enrolled independent pharmacies shall be defaulted to the lowest dispensing tier until the next claims volume survey is conducted.

(3) All chain affiliated pharmacies shall be exempt from completing the annual claims volume survey.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 184.750, 184.770, 409.050 & 414.065

Stats. Implemented: ORS 414.065

Hist.: AFS 51-1983(Temp), f. 9-30-83, ef. 10-1-83; AFS 56-1983, f. 11-17-83, ef. 12-1-83; AFS 41-1984(Temp), f. 9-24-84, ef. 10-1-84; AFS 1-1985, f. & ef. 1-3-85; AFS 54-1985(Temp), f. 9-23-85, ef. 10-1-85; AFS 66-1985, f. 11-5-85, ef. 12-1-85; AFS 13-1986(Temp), f. 2-5-86, ef. 3-1-86; AFS 36-1986, f. 4-15-86, ef. 6-1-86; AFS 52-1986, f. & ef. 7-2-86; AFS 12-1987, f. 3-3-87, ef. 4-1-87; AFS 28-1987(Temp), f. & ef. 7-14-87; AFS 50-1987, f. 10-20-87, ef. 11-1-87; AFS 41-1988(Temp), f. 6-13-88, cert. ef. 7-1-88; AFS 64-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0101; AFS 63-1989(Temp), f. & cert. ef. 10-17-89; AFS 79-1989, f. & cert. ef. 12-21-89; HR 20-1990, f. & cert. ef. 7-9-90, Renumbered from 461-016-0260; HR 29-1990, f. 8-31-90, cert. ef. 9-1-90; HR 21-1993(Temp), f. & cert. ef. 9-1-93; HR 12-1994, f. 2-25-94, cert. ef. 2-27-94; OMAP 5-1998(Temp), f. & cert. ef. 2-11-98 thru 7-15-98; OMAP 22-1998, f. & cert. ef. 7-15-98; OMAP 1-1999, f. & cert. ef. 2-1-99; OMAP 50-2001(Temp) f. 9-28-01, cert. ef. 10-1-01 thru 3-1-02; OMAP 60-2001, f. & cert. ef. 12-11-01; OMAP 32-2003(Temp), f. & cert. ef. 4-15-03 thru 9-15-03; OMAP 57-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 7-2004, f. 2-13-04 cert. ef. 3-15-04; OMAP 19-2004(Temp), f. & cert. ef. 3-15-04 thru 4-14-04; OMAP 21-2004, f. 3-15-04, cert. ef. 4-15-04; OMAP 19-2005, f. 3-21-05, cert. ef. 4-1-05; OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08; DMAP 40-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12

410-122-0186

Payment Methodology

(1) The Division of Medical Assistance Programs (Division) utilizes a payment methodology for covered durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) which is generally based on the 2010 Medicare fee schedule.

(a) Division fee schedule amount is 80.0% of 2010 Medicare Fee Schedule for items covered by Medicare and the Division, except for:

(i) Ostomy supplies fee schedule amounts are 95.4% of 2010 Medicare Fee Schedule (See Table 122-0186-1 for list of codes subject to this pricing); and

(ii) Prosthetic and Orthotic fee schedule amounts (L-codes) 83% of 2010 Medicare Fee Schedule; and

(iii) Complex Rehabilitation/Wheelchair fee schedule amounts are 90.5% of 2010 Medicare Fee Schedule (See Table 122-0186-2 for list of codes subject to this pricing);

(b) For items that are not covered by Medicare, but covered by the Division, the fee schedule amount will be calculated by reducing the Division’s latest published rates for the year 2010 by 7.6%.

(2) Payment is calculated using the Division fee schedule amount, or the actual charge submitted, whatever is lowest.

(3) The Division reimburses for the lowest level of service, which meets medical appropriateness. See OAR 410-120-1280 Billing and 410-120-1340 Payment.

(4) Reimbursement for durable medical equipment, miscellaneous (E1399) and other wheelchair accessories (K0108) is capped as follows:

(a) E1399 – $5772.00;

(b) K0108 – $11,913.41.

(5) Reimbursement for codes E1399 and K0108 and any code that requires manual pricing is determined as the lowest amount, verifiable with documentation submitted by DME provider to Division, of the following, plus 20 percent:

(a) Manufacturer’s invoice; or

(b) Manufacturer’s bill to provider;

(6) When requesting prior authorization (PA) for items billed at or above $150, the DMEPOS provider:

(a) Must submit a copy of:

(A) The items from (5)(a) or (b) that will be used to bill; and,

(B) Name of the manufacturer, description of the item, including product name/model name and number, serial number if applicable and technical specifications;

(b) May be required to submit a picture of the item.

(7) The DMEPOS provider must submit verification for items billed with codes A4649 (surgical supply; miscellaneous), E1399 (durable medical equipment, miscellaneous) and K0108 (wheelchair component or accessory, not otherwise specified) when no specific Healthcare Common Procedure Coding System (HCPCS) code is available and an item category is not specified in chapter 410, division 122 rules. Verification can come from an organization such as the Medicare Pricing, Data Analysis and Coding (PDAC) contractor.

(8) The Division may review items that exceed the maximum allowable/cap on a case-by-case basis. For these situations, the provider must submit the following documentation:

(a) Documentation that supports the client meets all of the coverage criteria for the less costly alternative; and

(b) A comprehensive evaluation by a licensed clinician (who is not an employee of or otherwise paid by a provider) which clearly explains why the less costly alternative is not sufficient to meet the client’s medical needs, and;

(c) The expected hours of usage per day, and;

(d) The expected outcome or change in client’s condition.

(9) For codes A4649, E1399 and K0108 when $150.00 or less per each unit:

(a) Only items that have received an official product review coding decision from an organization such as PDAC with codes A4649, E1399 or K0108 may be billed to the Division. These products may be listed in the PDAC Durable Medical Equipment Coding System Guide (DMECS) DMEPOS Product Classification Lists;

(b) Subject to service limitations of the Division’s rules;

(c) PA is not required.

(d) Billed charge to Division must not exceed manufacturer’s invoice, or manufacturer’s bill to provider plus 20 percent. Provider is required to retain documentation of invoice or bill to allow Division to verify.

(10) Table 122-0186-1: Ostomy Codes priced at 95.4% of 2010 Medicare.

(11) Table 122-0186-2: Complex Rehabilitation/Wheelchair Codes priced at 90.5% of 2010 Medicare Fee Schedule.

[ED. NOTE: Tables referenced are available from the agency.]

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05; OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07; DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 15-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12

410-122-0630

Incontinent Supplies

(1) The Division of Medical Assistance Programs (Division) may cover incontinent supplies for urinary or fecal incontinence as follows:

(a) Category I Incontinent Supplies – For up to 200 units (any code or product combination in this category) per month, unless documentation supports the medical appropriateness for a higher quantity. For quantities over this limit a prior authorization will be required;

(b) Category II Underpads:

(A) Disposable underpads (T4541 and T4542): For up to 100 units (any combination of T4541 and T4542) per month, unless documentation supports the medical appropriateness for a higher quantity, up to a maximum of 150 units per month;

(B) Reusable/washable underpads: (T4537 and T4540) For up to eight units (any combination of T4537 and T4540) in a 12 month period;

(C) Category II Underpads are separately payable only with Category I Incontinent Supplies;

(D) T4541 and T4542 are not separately payable with T4537 and T4540 for the same dates of service or anticipated coverage period. For example, if a provider bills and is paid for eight reusable/washable underpads on a given date of service, a client would not be eligible for disposable underpads for the subsequent 12 months;

(c) Category III Washable Protective Underwear:

(A) For up to 12 units in a 12 month period;

(B) Category III Washable Protective Underwear are not separately payable with Category I Incontinent Supplies for the same dates of service or anticipated coverage period. For example, if a provider bills and is paid for 12 units of T4536 on a given date of service, a client would not be eligible for Category I Incontinent Supplies for the subsequent 12 months;

(d) The following services require prior authorization (PA):

(A) A4335 (Incontinence supply; miscellaneous); and

(B) A4543 (Disposable incontinence product, brief/diaper, bariatric, each);

(C) Quantity of supplies greater than the amounts listed in this rule as the maximum monthly utilization (e.g., more than 200 units/month of Category I Incontinent Supplies, or 100 gloves/month).

(2) Incontinent supplies are not covered:

(a) For nocturnal enuresis; or

(b) For children under the age of three.

(3) A provider may only submit A4335 when there is no definitive Healthcare Common Procedure Coding System (HCPCS) code that meets the product description.

(4) Documentation requirements:

(a) The client’s medical records must support the medical appropriateness for the services provided or being requested by the medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider, including, but not limited to:

(A) For all categories, the medical reason and condition causing the incontinence; and

(B) When a client is using urological or ostomy supplies at the same time as codes specified in this rule, information which clearly corroborates the overall quantity of supplies needed to meet bladder and bowel management is medically appropriate;

(C) When requesting PA for T4543 (Bariatric Brief/Diaper) submit product information showing that item is size XXL or larger. The request shall also include client weight and measurements that support the use of the bariatric incontinence product. (e.g. client weight, waist/hip size) These items are manually priced and follow payment methodology outlined in OAR 410-122-0186.

(b) For services requiring PA, submit documentation as specified in (4)(a)(A), (B) and (C);

(c) The DMEPOS provider is required to keep supporting documentation on file and make available to the Division on request.

(5) Quantity specification:

(a) For PA and reimbursement purposes, a unit count for Category I–III codes is considered as single or individual piece of an item and not as multiple quantity;

(b) If an item quantity is listed as number of boxes, cases or cartons, the total number of individual pieces of that item contained within that respective measurement (box, case or carton) must be specified in the unit column on the PA request. See table 122-0630-2;

(c) For gloves (Category IV Miscellaneous), 100 gloves equal one unit.

(6) Table 122-0630-1

(7) Table 122-0630-2

[ED. NOTE: Tables referenced are available from the agency.]

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 64-2001, f. 12-28-01, cert. ef. 1-1-02; OMAP 47-2002, f. & cert. ef. 10-1-02; OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 76-2003, f. & cert. ef. 10-1-03; OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05; OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05; OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06; DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12

410-127-0060

Reimbursement and Limitations

(1) Reimbursement. The Division of Medical Assistance Programs (Division) reimburses home health services on a fee schedule by type of visit (see home health rates and copayment chart on the Oregon Health Authority (OHA) Web site at: http://www.dhs.state.or.us/policy/healthplan/guides/homehealth/main.html).

(2) The Division shall reimburse home health services at a level of 74% of Medicare costs reported on the audited or most recently accepted Medicare Cost Reports that were available to the Division in November of 2009.

(3) At the Division’s discretion, the Division may recalculate its home health rates every other year. The Division may request the Medicare Cost Reports from home health agencies with a due date, and may recalculate rates based on the Medicare Cost Reports received by the requested due date. It is the responsibility of the home health agency to submit requested cost reports by the date requested.

(4) The Division reimburses only for service which is medically appropriate.

(5) Limitations:

(a) Limits of covered services:

(A) Skilled nursing visits are limited to two visits per day with payment authorization;

(B) All therapy services are limited to one visit or evaluation per day for physical therapy, occupational therapy or speech and language pathology services. Therapy visits require payment authorization;

(C) The Division will authorize home health visits for clients with uterine monitoring only for medical problems, which could adversely affect the pregnancy and are not related to the uterine monitoring;

(D) Medical supplies must be billed at acquisition cost and the total of all medical supply revenue codes may not exceed $50 per day. Only supplies that are used during the visit or the specified additional supplies used for current client/caregiver teaching or training purposes as medically necessary are billable. Client visit notes must include documentation of supplies used during the visit or supplies provided according to the current plan of care;

(E) Durable medical equipment must be obtained by the client by prescription through a durable medical equipment provider.

(b) Not covered service:

(A) Service not medically appropriate;

(B) A service whose diagnosis does not appear on a line of the Prioritized List of Health Services which has been funded by the Oregon Legislature (OAR 410-141-0520);

(C) Medical Social Worker service;

(D) Registered dietician counseling or instruction;

(E) Drug and or biological;

(F) Fetal non-stress testing;

(G) Respiratory therapist service;

(H) Flu shot;

(I) Psychiatric nursing service.

ED. NOTE: Tables referenced are available from the agency.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: PWC 682, f. 7-19-74, ef. 8-11-74; PWC 798, f. & ef. 6-1-76; PWC 854(Temp), f. 9-30-77, ef. 10-1-77 thru 1-28-78; Renumbered from 461-019-0420 by Chapter 784, Oregon Laws 1981 & AFS 69-1981, f. 9-30-81, ef. 10-1-81; SSD 4-1983, f. 5-4-83, ef. 5-5-83; SSD 10-1990, f. 3-30-90, cert. ef. 4-1-90; HR 28-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 411-075-0010; HR 14-1992, f. & cert. ef. 6-1-92; HR 15-1995, f. & cert. ef. 8-1-95; OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 77-2003, f. & cert. ef. 10.1.03; DMAP 16-2007, f. 12-5-07, cert. ef. 1-1-08; DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12

410-130-0595

Maternity Case Management

(1) The primary purpose of the Maternity Case Management (MCM) program is to optimize pregnancy outcomes, including reducing the incidence of low birth weight babies. MCM services are tailored to the individual client needs. These services are provided face-to-face throughout the client’s pregnancy, unless specifically indicated in this rule.

(2) This program:

(a) Is available to all pregnant clients receiving Medical Assistance Program coverage;

(b) Expands perinatal services to include management of health, economic, social and nutritional factors through the end of pregnancy and a two-month postpartum period;

(c) Must be initiated during the pregnancy and before delivery;

(d) Is an additional set of services over and above medical management of pregnant clients;

(e) Allows billing of intensive nutritional counseling services.

(3) Any time there is a significant change in the health, economic, social, or nutritional factors of the client, the prenatal care provider must be notified.

(4) Only one provider at a time may provide MCM services to the client. The provider must coordinate care to ensure that duplicate claims for MCM services are not submitted to the Division.

(5) Definitions:

(a) Case Management – An ongoing process to assist and support an individual pregnant client in accessing necessary health, social, economic, nutritional, and other services to meet the goals defined in the Client Service Plan (CSP)(defined below);

(b) Case Management Visit – A face-to-face encounter between a Maternity Case Manager and the client that must include two or more specific training and education topics, address the CSP and provide an on-going relationship development between the client and the visiting provider.

(c) Client Service Plan (CSP) – A written systematic, client coordinated plan of care which lists goals and actions required to meet the needs of the client as identified in the Initial Assessment (defined below) and includes a client discharge plan/summary;

(d) High Risk Case Management – Intensive level of services provided to a client identified and documented by the Maternity Case Manager or prenatal care provider as being high risk;

(e) High Risk Client – A client who has a current (within the last year) documented alcohol, tobacco or other drug (ATOD) abuse history, or who is 17 or under, or has other conditions identified by the case manager anytime during the course of service delivery;

(f) Home/Environmental Assessment – A visit to the client’s primary place of residence to assess the health and safety of the client’s living conditions;

(g) Initial Assessment – Documented, systematic collection of data with planned interventions as outlined in a CSP to determine current status and identify needs and strengths in physical, psychosocial, behavioral, developmental, educational, mobility, environmental, nutritional, and emotional areas;

(h) Nutritional Counseling – Intensive nutritional counseling for clients who have at least one of the conditions listed under Nutritional Counseling (12)(a)(A–I) in this rule;

(i) Prenatal/Perinatal care provider – The physician, licensed physician assistant, nurse practitioner, certified nurse midwife, or licensed direct entry midwife providing prenatal or perinatal (including labor and delivery) and/or postnatal services to the client;

(j) Case Management Visit Outside the Home – An encounter outside the client’s home between a Maternity Case Manager and the client where identical services of a Case Management Home Visit (G9012) are provided.

(6) Maternity case manager qualifications:

(a) Maternity case managers must be currently licensed as a:

(A) Physician;

(B) Physician assistant;

(C) Nurse practitioner;

(D) Certified nurse midwife;

(E) Direct entry midwife;

(F) Social worker; or

(G) Registered nurse;

(b) The maternity case manager must be a Division enrolled provider or deliver services under an appropriate Division enrolled provider. See provider qualifications in the Division’s General Rule 410-120-1260.

(c) All of the above must have a minimum of two years of related and relevant work experience;

(d) Other paraprofessionals may provide specific services with the exclusion of the Initial Assessment (G9001) while working under the supervision of one of the practitioners listed above in this section;

(e) The maternity case manager must sign off on all services delivered by a paraprofessional;

(f) Specific services not within the recognized scope of practice of the provider of MCM services must be referred to an appropriate discipline.

(7) Nutritional counselor qualifications – nutritional counselors must be:

(a) A licensed dietician (LD) licensed by the Oregon Board of Examiners of Licensed Dieticians; and

(b) A registered dietician (RD) credentialed by the Commission on Dietetic Registration of the American Dietetic Association (ADA).

(8) Documentation requirements:

(a) Documentation is required for all MCM services in accordance with Division General Rule 410-120-1360; and

(b) A correctly completed Division form 2470, 2471, 2472 and 2473 or their equivalents meet minimum documentation requirements for MCM services.

(9) G9001 – Initial Assessment must be performed by a licensed maternity case manager as defined under (6)(a)(A–G) in this rule:

(a) Services include:

(A) Client assessment as outlined in the “Definitions” section of this rule;

(B) Development of a CSP that addresses identified needs;

(C) Making and assisting with referrals as needed to:

(i) A prenatal care provider;

(ii) A dental health provider;

(D) Forwarding the Initial Assessment and the CSP to the prenatal care provider;

(E) Communicating pertinent information to the prenatal care provider and others participating in the client’s medical and social care;

(b) Data sources relied upon may include:

(A) Initial Assessment;

(B) Client interviews;

(C) Available records;

(D) Contacts with collateral providers;

(E) Other professionals; and

(F) Other parties on behalf of the client;

(c) The client’s record must reflect the date and to whom the Initial Assessment was sent;

(d) The Initial Assessment (G9001) is billable once per pregnancy per provider and must be performed before providing any other MCM services. Only a Home/Environmental Assessment (G9006) and a Case Management Home Visit (G9012) or Case Management Visit Outside the Home (G9011) may be performed and billed on the same day as an Initial Assessment.

(10) G9002 – Case Management includes:

(a) Face-to-face client contacts;

(b) Implementation and monitoring of a CSP:

(A) The client’s records must include a CSP and written updates to the plan;

(B) The CSP includes determining the client’s strengths and needs, setting specific goals and utilizing appropriate resources in a cooperative effort between the client and the maternity case manager;

(c) Care coordination as follows:

(A) Contact with Department of Human Services (Department) case worker, if assigned;

(B) Maintain contact with prenatal care provider to ensure service delivery, share information, and assist with coordination;

(C) Contact with other community resources/agencies to address needs;

(d) Linkage to client services indicated in the CSP:

(A) Make linkages, provide information and assist the client in self-referral;

(B) Provide linkage to labor and delivery services;

(C) Provide linkage to family planning services as needed;

(e) Ongoing nutritional evaluation with basic counseling and referrals to nutritional counseling, as indicated;

(f) Utilization and documentation of the “5 As” brief intervention protocol for addressing tobacco use (US Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence, 2008). Routinely:

(A) Ask all clients about smoking status;

(B) Advise all smoking clients to quit;

(C) Assess for readiness to try to quit;

(D) Assist all those wanting to quit by referring them to the Quitline and/or other appropriate tobacco cessation counseling and provide motivational information for those not ready to quit;

(E) Arrange follow-up for interventions;

(g) Provide training and education on all mandatory topics – Refer to Table 130-0595-2 in this rule;

(h) Provide client advocacy as necessary to facilitate access to benefits or services;

(i) Assist client in achieving the goals in the CSP;

(j) G9002 is billable when three months or more of services were provided. Services must be initiated during the prenatal period and carried through the date of delivery;

(k) G9002 is billable once per pregnancy.

(11) G9005 – High Risk Case Management:

(a) Enhanced level of services that are more intensive and are provided in addition to G9002;

(b) A client can be identified as high risk at any time when case management services are provided, therefore G9005 can be billed after 3 months of case management services.

(c) G9005 is billable only once per pregnancy per provider.

(d) G9002 can not be billed in addition to G9005.

(12) S9470 – Nutritional counseling:

(a) Is available for clients who have at least one of the following conditions:

(A) Chronic disease such as diabetes or renal disease;

(B) Hematocrit (Hct) less than 34 or hemoglobin (Hb) less than 11 during the first trimester, or Hct less than 32 or Hb less than 10 during the second or third trimester;

(C) Pre-gravida weight under 100 pounds or over 200 pounds;

(D) Pregnancy weight gain outside the appropriate Women, Infants and Children (WIC) guidelines;

(E) Eating disorder;

(F) Gestational diabetes;

(G) Hyperemesis;

(H) Pregnancy induced hypertension (pre-eclampsia); or

(I) Other identified conditions;

(b) Documentation must include all of the following:

(A) Nutritional assessment;

(B) Nutritional care plan;

(C) Regular client follow-up;

(c) Can be billed in addition to other MCM services;

(d) S9470 is billable only once per pregnancy.

(13) G9006 – Home/Environmental Assessment:

(a) Includes an assessment of the health and safety of the client’s living conditions with training and education of all topics as indicated in Table 130-0595-1 in this rule;

(b) G9006 may be billed only once per pregnancy, except an additional Home/Environmental Assessments may be billed with documentation of problems which necessitate follow-up assessments or when a client moves. Documentation must be submitted with the claim to support the additional Home/Environment Assessment.

(14) G9011 – Case Management Visit Outside the Home:

(a) A face-to-face encounter between a maternity case manager and the client in a place other than the home which meets all requirements of a Case Management Home Visit (G9012) or a telephone encounter when a face-to-face Case Management Visit is not possible or practical;

(b) G9011 is billable in lieu of a Case Management Home Visit and counted towards the total number of Case Management Home Visits (see G9012 for limitations).

(15) G9012 – Case Management Home Visit:

(a) Each Case Management Home Visit must be performed in the client’s home and must include:

(A) An evaluation and/or revision of objectives and activities addressed in the CSP: and

(B) At least two training and education topics listed in Table 130-0595-2 in this rule;

(b) Four Case Management Home Visits (G9012) may be billed per pregnancy. Case Management Visits Outside the Home (G9011) are included in this limitation;

(c) Six additional Case Management Home Visits may be billed if the client is identified as high risk;

(A) These additional six visits may only be billed with or after High Risk Case Management (G9005) has been billed. Case Management Visits Outside the Home (G9011) are included in this limitation.

(19) Table 130-0595-1

(20) Table 130-0595-2

[ED. NOTE: Tables & Forms referenced are available from the agency.]

Stat. Auth.: ORS 409.050 & 414.065

Stats. Implemented: ORS 414.065

Hist.: AFS 57-1987, f. 10-29-87, ef. 11-1-87; AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0200 & 461-014-0201; AFS 54-1989(Temp), f. 9-28-89, cert. ef. 10-1-89; AFS 71-1989, f. & cert. ef. 12-1-89; HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0580; HR 19-1991, f. 4-12-91, cert. ef. 5-1-91; HR 43-1991, f. & cert. ef. 10-1-91; HR 42-1994, f. 12-30-94, cert. ef. 1-1-95; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 34-1998, f. & cert. ef. 10-1-98; OMAP 17-1999, f. & cert. ef. 4-1-99; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 51-2002, f. & cert. ef. 10-1-02; OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03; Renumbered from 410-130-0100, OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 18-2009, f. 6-12-09, cert. ef. 7-1-09; DMAP 8-2010(Temp), f. 4-13-10, cert. ef. 4-15-10 thru 10-1-10; DMAP 24-2010, f. & cert. ef. 9-1-10; DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.

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